Patients hospitalized with acute heart failure (AHF) receive variable and often substandard care, even when they are part of a randomized clinical trial, researchers reported in the July 30 edition of Circulation.
The study authors, led by Jonathan G. Howlett, MD, of the University of Calgary in Canada utilized data from the Acute Study Clinical Effectiveness of Nesiritide in Decompensated Heart Failure Trial (ASCEND-HF). ASCEND-HF was a large international clinical trial carried out between 2007 and 2010 to determine the effectiveness of nesiritide in addition to standard care. There were more than 7,000 participants who were admitted to 398 hospitals in five parts of the world.
Howlett and his colleagues analyzed the variations in standard AHF quality of care measures (QCM) and composite performance measures (CPM) among the five geographical regions used in ASCEND-HF. They determined the percentage of adherence to the various measures.
Among the QCMs they assessed were the use of different drugs, including ACE inhibitors/angiotensin receptor blockers (ARBs), beta-blockers and anticoagulants; the use of implantable cardioverter defibrillators (ICDs) and cardiac resynchonization therapy with or without ICDs.
“In this study, we found large gaps in conformity to quality measures and a high variability between geographical regions without a clear pattern,” the authors found.
Adherence to the different quality indicators ranged from 0 percent to 89 percent and also ranged from region to region. For example, 63 percent of eligible patients were prescribed ACE inhibitors/ARBs, and conformity rate was highest in Central Europe at 80 percent. North American participating hospitals had the highest conformity rate with the use of beta blockers at 89 percent. Overall, the rate was 76 percent.
“Of all potential performance opportunities, 19,076 of 32,268 (59 percent) were met, with Central Europe highest at 64 percent, followed by North America (63 percent), Western Europe (61 percent), Latin America (56 percent), and Asia Pacific (51 percent),” they noted.
They also found a statistically significant, although small, increase in adherence throughout most of the regions.
In addition, there was greater adherence to more established treatments, such as blood pressure control and beta-blockers, than to newer therapies, such as the use of cardiac devices.
There are several possible reasons for the variability in conformity. Clinicians may value the numerous treatment options differently, or subgroups of the populations may lead to greater use of therapies geared toward those segments.
Additionally, certain therapies may be logistically difficult to implement for a number of reasons. For example, the use of oral anticoagulants or aldosterone antagonists require a high level of monitoring. Device therapy, as another example, needs to be done in facilities with appropriate resources.
“Specific measures designed to improve performance measures should be implemented even within multicenter clinical trials,” the authors wrote.